Skepticism

EVENTS

How not to run a public health program

Apparently, India has these ‘voluntary’ sterilization drives to reduce overpopulation. I put ‘voluntary’ in quotes because these kinds of programs have an ethical catch: they pay women a small amount to have the service done, so for some desperately poor women, it may be more of a necessary sacrifice they have to make to survive. There may be another catch, too: at least one of them was incompetently run.

More than 80 women underwent surgery for laparoscopic tubectomies at a free government-run camp in the central state of Chhattisgarh on Saturday. Of these, about 60 fell ill shortly afterwards, officials in the state said.

Eight have died. Ten are in critical care. I don’t think a 75% failure rate for a routine operation is going to reassure people that this is a safe health choice.

You might be wondering how this could happen. Wonder no more.

The Indian Express daily said the operations in Chhattisgarh were carried out by a single doctor and his assistant in about five hours. “There was no negligence. He is a senior doctor. We will probe [the incident],” the chief medical officer of Bilaspur, RK Bhange, told the newspaper.

I don’t think a non-negligent doctor would whip through 80 patients at the average rate of one every 3.75 minutes. To the problem of a hack with a knife, let’s add the incompetent, CYA-management of ranking medical administrators in the district. Everyone with any confidence that there will be a serious “probe” of the matter, raise your hands.

Comments

Well, that rate of speed may explain people falling ill. Does the doctor just stand there with his surgical equipment and plunge into one woman’s body and when he’s done they wheel in the next and he plunges right in without so much as washing up or switching to new sterile tools?

But really, sterilization programs are always enormously problematic, involuntary ones are outright evil, but if you’re going to have one, wouldn’t it make more sense to sterilize the men? It takes two to tango, and men are not limited, biologically, in the number of pregnancies they can be involved in. It really is about blaming women. And the fact that it’s mostly men making the decisions.

Sure. I mean what more proof of non-negligence could you possibly want? He’d been promoted! No-one who’s been promoted is ever negligent. Obviously he’s just used his senior doctor super powers to be able to sterilise his instruments in mere seconds, and it’s pure coincidence that they all got sick that day. I mean coincidences happen, right? And sometimes they kill poor women that no-one cares about, so that’s probably what happened here. No point in making waves, after all. Wouldn’t want a senior doctor to get in trouble just because a few nobodies die, would we?

To get a sense of the scale of how rushed this is, I asked a surgeon I know how long they think this would take to do properly in a sort of best-case scenario (good surgeon well-practiced in this particular surgery, plenty of sterile equipment at the ready, assistants handling as much as possible — think of a monthly spay clinic at your local pet store). Their estimate: “15-20 minutes, maybe faster”

@5 gussnarp, “It takes two to tango, and men are not limited, biologically, in the number of pregnancies they can be involved in.

Emphasis mine. That’s exactly why you wouldn’t target men. If you limit one man, well, then some other man can just come in and take his place, so you’ve accomplished little. If you want to tackle this problem logistically,* then your best bet is to further limit the part of the population that’s already limited.

* And this is why I hated leaving this comment. We really shouldn’t be thinking logistically. (I can’t help it sometimes; I’m an engineer. It’s my life.) We should be, you know, treating people as people.

One potential problem women could have with sterilization of men: “Sure babe, I am sterilized.” (Has sex with her and runs away.) If a woman tried to pull the same trick on a man, she would still the one stuck with the fetus. I don’t intend this to be an argument against sterilization of men, btw. I resent living in a world where (you need a license to drive a car, but) any idiot can produce children.

Leo @ 12 – Sure, it sounds horrible. But when you have 1.1 BILLION people, and no flattening of the population growth curve in sight, Logistically is the only way of thinking that will actually do any good.

Of course, most of these programs that have been carried out rely on the terrible assumption that there are certain women we need to stop from reproducing. Usually poor, minority women. If we were to make the same assumption about men, then we ought to be able to find the men who are the problem and sterilize them and get far more bang for the buck, as it were. Which goes back to showing what a horrible idea these programs actually are. They’re not so much about sterilizing say, x percent of the population in child bearing years equally, they’re about sterilizing poor people or “undesirables”.

What actually works is empowering women. Allowing them autonomy over their own bodies as well as economic autonomy and affordable access to a range of birth control options. Turns out in most cases if you accomplish that, birth rates plummet with no further incentive or involuntary programs.

Where I am, it does take a bit longer than that, with the prep time included. But it’s a small clinic and we don’t do a lot of kitty neuters – a few a week, in a busy week.
Anyway, I can’t imagine doing a ligation by any technique in that little time. Something very wrong there.

I work at a humane society, so our vets are doing 30+ surgeries a day, both private and in-house animals. I used to work in a day practice where the actual surgery time for a spay would be 30 to 45 minutes. It’s simply a matter of practice, and confidence in your technique.

Self-ties on neuters take only a few seconds, so that’s why those surgeries are so fast.

@Sili #4: There is a sexist-but-rational reason for this: a single man* can theoretically impregnate a different woman* every twenty to thirty minutes, while a woman can only produce a new infant every nine months or so. In order to control population without radically altering norms of behavior**, one must control female fertility.

And, reading further, I see others have already covered this. gussnarp covers the evidenced practices that are preferable to sterilization programs in comment #15.

*I’m using social gender categories for convenience; as always, it should be noted that some men can become pregnant and some women can contribute sperm to cause a pregnancy in another person.
**Obviously, widespread condom use and substitution of non-procreative sexual activity for potentially-procreative sexual activity except in cases where one specifically wants to procreate could work just as well, no surgery required. This also presumes all, or at least most, sexual activity is actually consensual and not forced or coerced – fighting rape culture is actually an environmental issue as well as an issue of gender equality and individual autonomy rights.

There is a sexist-but-rational reason for this: a single man* can theoretically impregnate a different woman* every twenty to thirty minutes, while a woman can only produce a new infant every nine months or so. – John @30

If you limit one man, well, then some other man can just come in and take his place, so you’ve accomplished little. – Leo @12

This would make sense if people were interchangeable fuck machines, but in reality, they’re not, and people don’t actually constantly fuck every potential partner; women don’t automatically cast aside infertile partners to find fertile ones to fuck, and men don’t automatically think “that idiot just got a vasectomy, better go fuck his wife”. If the partner of a woman in a long-term, monogamous relationship partner is sterilized, then that pair probably won’t have any(more) children. I know that if my spouse was sterilized, my chances of getting pregnant would greatly decrease to near-zero, because in the terms of our relationship, I’m not going to be sleeping with other people; as far as my spouse goes, while I’m confident that he wouldn’t be having sex with other people either, even if he did, the procedure would also prevent him from unintentional pregnancies with other partners.

So considering that people aren’t interchangeable fuck machines, I believe that offering similar to programs* to men (which they apparently were, dubiously and by force, in the 1960s and 1970s) would in fact help people who don’t want any more children. I have also heard that a vasectomy is less complicated (and thus, less risky) than a tubectomy (but I’m not a medical professional, so I don’t really know). That’s why I’m sure that at least a small part of the focus on reducing women’s fertility rather than men’s is tied up with patriarchal ideas of fertility, that if a man can’t father children, then he is no longer a mythical “real man” (and, anecdotally, I have heard men in the US express this exact opinion when justifying their decision to “push” their wives into getting tubal litigations). Another reason, in India at least, could be the big fuck-up by the government in the past with sterilizing men (http://abcnews.go.com/Health/wireStory/indian-women-die-27-ill-sterilization-26824394).

*That being said, even without potential sexist undertones, this program is disgusting with its coercive measures, lack of oversight, and obvious classism, and this shit shouldn’t be pushed onto anybody, irregardless of what chromosomes they might be donating. However, enhancing access to education and contraceptives–no cutting people up required!–has the byproduct of reducing unsustainable birth rates quite nicely.

IN a story on NPR the most likely cause of the problems was said to be suspected contaminated or counterfeit drugs, not the surgical technique. There was a report that patients were getting sick after the drug was administered.

As for how you can do a sterilization in a very few minutes, well .. I used to work in a hospital where a specialist would schedule as many of the same procedure as possible on the same day. They set up an assembly line with a number of operating rooms being used and several surgical and support terms handling prep, induction, and post-operative handling.

All the routine surgical steps, like the initial incision and closing, being done by a secondary doctors. The main guy comes in once all the grunt work is done and does his thing in a few minutes and steps off to the next room. He did essentially the same operation perhaps a dozen times in a few hours.

Everything was staggered so that no time was wasted. As one was being cut on another one or two were being prepped. If a patient took longer to pass a stage they might be moved back on the list. Once a patient was closed up a clean-up crew stepped in to clean the OR. Followed by a team to set it up for the next patient to get rolled in.

It was a rather impressive logistical operation with perhaps two, perhaps three, dozen people coordinated by a head nurse and the whole thing planned out on a white board. This was before computers were so common.

To a lot of people with TV and movie induced romantic illusions the practice is barbaric but all the reports are that this sort of tight scheduling can lead to better results simply because a team that does more of one operation tends to be good at it. It is the surgeons that are called to do an operation once in a blue moon that make mistakes. The literature says that there are more problems if the surgeon goes on vacation and comes back after a week off.

If you have a choice for surgery you want a surgeon that does the operation a lot and you want to be placed in the middle of the run where they have warmed up, hit their stride, but before fatigue sets in.

On a more personal not I once had to sterilize two dozen mice. It took a while to do the first. By the time I was on my last one I had a system. The last ones I did were neater, less traumatized, and they recovered faster. Practice makes for better outcomes.

Actually the problem is not enough doctors. Put it this way. I have put up more work this week than most American House Officers/Interns. 80 hours is a big deal, Too bad I am going to hit 120 and have no days off.

These aren’t lap sterilisation but abdominal. You can’t go that fast on lap sterilisations. An abdominal can be done in around about that time IF you have a prep team.

So the anaesthetist gives the spinal anasthesia. And someone other than the senior Obs/Gynae places the incision and externalises the uterus. The actual sterilisation is simple. The major time is spent closing and opening rather than sterilising. (No seriously. Identify fallopian tubes, hold with Babcock’s forceps. Place two curved artery forceps and cut away the middle tubal section. Then ligate. Repeat. This takes 2 to 5 minutes for me)

Then someone else closes. In my hospital it is usually me with a senior surgeon supervising in case something goes wrong but now even the surgeon leaves cause I can throw stitches quickly and neatly and it is good practice for me. I go slower than they do but I am not so slow I hold up the line because people start cleaning down the surgery while I am closing up. By the time I am done all the paper work is over and we can turn around the theatre for the next surgery in as little as 10 minutes.

Anasthesia recovery can be done in another room. Hell? In India we deliver babies in “non-private rooms”. So pregnant mothers are often in birthing tables side by side because one doctor handles multiple cases.

The alternative? Work like e do in the USA and only 3 or 4 patients get treated.

Oh and FYI? The rule is doctors refuse to sterilse women with less than 2 children. Only after 2 children do they suggest sterilisation. And if men would get vasectomies we wouldn’t have this problem.

Counterfeit drugs are also a problem. As are counterfeit medical equipment. I myself have had venflon (IV cannula ) that simply would not pierce veins because they weren’t made out of surgical grade equipment.